Nailing subtrochanteric short femur fractures

Nailing subtrochanteric short femur fractures

1. Nailing Subtroch
Short Segment
Femur Fractures
Amir Matityahu, MD
Professor of Orthopaedic Surgery
UCSF and SFGH Departments of Orthopaedic Surgery

2. Conflict of Interest
Designed variable angle cephallomedullary
femoral nail
Ownership EPIX Orthopaedics

3. Malalignment
Associated with
–Proximal 1/3 fx
–Distal 1/3 fx
–Comminuted
segmental fx
•Less Likely in
–Middle 1/3 fx
–Stable fx pattern
•Not due to Method
of treatment
•Anterograde vs
Retrograde
•Troch vs Piriformis

4. Anatomy of SubtrochFractures
Muscle Pull
–Proximal
•Abduction
•Flexion
•External rotation
–Distal
•Short
•Medial
•External rotation
Short
Proximal
Segment

5. Forces after fixation

6. Malalignment and Varus in
SubtrochFxis Common
Factors that lead to nonunion
Varus and Anterior Apex Angulation ≈10-20%
Medial Cortical abutment
Nail autodynamization
Shulka, Cephallomedullarynails subtrochanteric fractures, Injury, 2007

7. Varus and Apex Anterior in Subtrochfractures
Nail without reduction

8. Treatment options
Cephalomedullarynail
–Axial stiffness
–Load to failure
–Cycles to failure
Fixed angle plate
–More lateral position
•Greater bending forces
•Decreased load to failure
•Decreased number of cycles to failure
Kuzyk, P et al. Intramedullary Versus Extramedullary Fixation for SubtrochantericFemurFractures. J OrthopTrauma.
2009;23(6):465-470
Biomechanical Study of IntramedullaryVersusExtramedullary Implants for Four Types of Subtrochanteric Femoral Fracture
Jie Wang MD,Haobo Jia MD,Xinlong Ma MD,Jianxiong Ma MD,Bin Lu MD,Haohao Bai MD,Ying Wang MD
Orthopaedic Surgery

9. OR Setup
Scissor position or Lateral Decubitus

10. preop c-arm
Make sure you can get a perfect lateral of head and neck

11. OR Set up
EM reduction

12. Prep anteriorly in case you need to push down

13. Subtrochanteric nails
Avoiding Varus
Proper insertion point
–Trochaformisstart site
Reduction before reaming

32. Trochanteric Femoral Nailing
starting point
Too Lateral
Blow out or Varus
Correct Too Medial
Valgus, Increased
leg length
Ostrumet al JOT 2005

33. Holland TAN TFN Gamma 2Gamma 3
Proximal bend 10 5 6 4 4
Rad of Curv300mm 350mm 150mm 300mm 200mm
Trochanteric Start
Ostrumet al JOT 2005

34. Know your nail’s anatomy
variable proximal bend and thickness
Tip of the greater troch may be too lateral
Holland TAN Gamma TFN
Ostrumet al JOT 2005

35. Piriformis Fossa is a posterior structure
Trochanter is bulbous

36. Trochanteric entry nail:
IS entryeasier to access?
–Watch out for the Oval
•Reaming sequentially causing an oval entry hole and varus
Ream ReamReam
Insert
Nail
OVAL

37. Avoid Varus with correct entry!
Avoid reaming laterally!
Avoid Oval by Use of one step reamer!

38. 85 year old female post PVA
Sup/peritrochantericfracture Jan 2006

40. TFN

41. 14°VARUS
Medial Translation

42. 2 years post op
Nonunion and Hardware Failure
30°
Varus
nonunion
100°
Neck-Shaft Angle

43. Lateral Decubitus Position

44. Steps for Troch Entry

67. Short Segment Femur Fracture
54 yomale jumper 30ft

69. TEN 38cm x 11 mm

70. Two screws into head

74. 67 year old cyclist

75. OTA Resident Lecture

83. Thank You